Variation in Prescriber Responses to Drug Safety Alert Messages: Disease, Symptom, or Red Herring?

I n this issue of JMCP, Feifer and James provide significant food for thought in their examination of geographic variation in the rate of automated drug safety alerts as well as prescriber response to such alerts. 1 Findings from this study suggest that the major influences on this variation are uncertain, as member demographics explained a relatively small proportion of the observed variance in alerting rates. The authors conclude that outreach and education are necessary to improve prescriber behavior where warranted. When broken down into the study's constituent parts, however , both measures of variation are linked to much broader considerations regarding the state of American health care practice. The rates of " alerting events " in this study varied considerably by state, ranging from 78 to 240 per 1,000 members. However, is this variation really surprising? After all, small-area variation in health care utilization and clinical practice is a well-documented phenomenon; 2,3 why should awareness of potential drug safety concerns be subject to any less variation? As an example, consider one of the clinical situations that Feifer and James present in Table 1 of their study report—the prescribing of stimulants for children with attention deficit hyperactivity disorder (ADHD) and significant cardiac structural or rhythm abnormalities. This is indeed a significant concern, but its calculus involves more than simple variation in prescriber awareness of the clinical problem. Indeed, the documented geographic variation in both the prevalence of diagnosed ADHD and receipt of ADHD medication is significant, with 2-to 3-fold variation reported in each measure by state of residence. 4 While there are no published data on variation in the prevalence of co-diagnosed ADHD and structural/rhythm abnormalities in children, it is not unreasonable to imagine this prevalence to be (a) relatively low; and (b) distributed in some disproportionate fashion regionally, perhaps in relation to the location of advanced pediatric cardiology services and/or children's hospitals. Variability in inappropriate prescribing is therefore likely to be a result of a complex interaction of disease epidemiology, practice variation, the likelihood of a given clinician encountering a relatively rare safety issue in practice, and many other concerns. As a clue for the development and targeting of a programmatic intervention to change prescribing behavior, it is also a red herring. Why? The answer can perhaps be found in the examination of Feifer and James' second key measure, the rate of successful therapy change per alerting event. The …

I n this issue of JMCP, Feifer and James provide significant food for thought in their examination of geographic variation in the rate of automated drug safety alerts as well as prescriber response to such alerts. 1 Findings from this study suggest that the major influences on this variation are uncertain, as member demographics explained a relatively small proportion of the observed variance in alerting rates. The authors conclude that outreach and education are necessary to improve prescriber behavior where warranted.
When broken down into the study's constituent parts, however, both measures of variation are linked to much broader considerations regarding the state of American health care practice. The rates of "alerting events" in this study varied considerably by state, ranging from 78 to 240 per 1,000 members. However, is this variation really surprising? After all, small-area variation in health care utilization and clinical practice is a well-documented phenomenon; 2,3 why should awareness of potential drug safety concerns be subject to any less variation?
As an example, consider one of the clinical situations that Feifer and James present in Table 1 of their study report-the prescribing of stimulants for children with attention deficit hyperactivity disorder (ADHD) and significant cardiac structural or rhythm abnormalities. This is indeed a significant concern, but its calculus involves more than simple variation in prescriber awareness of the clinical problem. Indeed, the documented geographic variation in both the prevalence of diagnosed ADHD and receipt of ADHD medication is significant, with 2-to 3-fold variation reported in each measure by state of residence. 4 While there are no published data on variation in the prevalence of co-diagnosed ADHD and structural/rhythm abnormalities in children, it is not unreasonable to imagine this prevalence to be (a) relatively low; and (b) distributed in some disproportionate fashion regionally, perhaps in relation to the location of advanced pediatric cardiology services and/or children's hospitals.
Variability in inappropriate prescribing is therefore likely to be a result of a complex interaction of disease epidemiology, practice variation, the likelihood of a given clinician encountering a relatively rare safety issue in practice, and many other concerns. As a clue for the development and targeting of a programmatic intervention to change prescribing behavior, it is also a red herring.
Why? The answer can perhaps be found in the examination of Feifer and James' second key measure, the rate of successful therapy change per alerting event. The geographic variation in this measure was actually fairly small-from 48.1% to 59.5% when examined by state. Small variation, but universally poor results-essentially, a flip of the coin as to whether a given alert would effect the appropriate change in therapy. In contrast to alerting event rates, these results get us closer to the true nature of a systematic and widespread problem that in actuality has relatively little to do with geographic variation.
On the surface, the availability of an automated alerting system such as the one described by Feifer and James would appear to have great utility to the overworked clinician. Findings from an empirical model of the potential downstream impact of an automated alert system suggested that, for every quarter-million prescriptions, more than 400 adverse drug events would be averted, preventing death or disability in nearly 50 patients, and substantially reducing numbers of unplanned hospitalizations as well as emergency department and office visits. 5 Physicians also appear to support the concept of such a system; survey responses from 184 physicians suggest that the majority feel that electronic prescribing improves quality of care, prevents medical errors, and enhances both patient satisfaction and clinician efficiency, and nearly two-thirds of survey participants reported modifying practice in some way in response to automated alerts. 6 Despite these positive signals, the clinician response to alerting systems in practice has been underwhelming. The 184 physician respondents in the above-mentioned survey were generally unsatisfied with drug interaction and allergy alerts, citing outdated information, failure to account for appropriate drug combinations, and an excessive volume of alerts. 6 Findings from another survey-based study indicated strong prescriber preference for use of printed material and pharmacist consults over electronic alerts for drug-drug interactions. 7 Not surprisingly then, rates at which automated alerts have been ignored or overridden are reported to be 90% or greater in studies of e-prescribing systems, even when such alerts are stratified by potential severity. 8 In the current environment, it is clear that any outreach tied to better response to alerts at the point of prescribing (the aforementioned red herring) will have limited utility at best. So too would outreach aimed at improving prescriber response to alerts, given the number of administrative burdens that the typical clinician already must deal with, the lack of coordination and communication between health care providers, and the absence of comprehensive primary patient care that is typical of health care practice in the United States.
Lack of response to electronic alerts is therefore a symptom

C O M M E N TA R Y
of the larger "disease"-the methods by which health care is planned, delivered, and reimbursed in this country. It is highly unlikely that the frequency of medication errors will greatly subside without substantial reform in communication between clinicians, coordination of care between settings, and linkage of payment to quality of patient care, whether or not automated alerting systems become de rigueur. Such change appears to be a long way off, even as the White House and Congress debate incremental reforms that may inch closer to a true system overhaul. The question that remains is, can anything be done now to reduce medication errors? The answer is yes, and many of the solutions are almost absurdly simple. Jenkins and Vaida describe a list of low-cost strategies feasible for any clinical practice to implement, as presented in Table  1. 9 Interestingly, e-prescribing is one of the strategies included. However, other approaches, such as highlighting whether a patient has a diagnosis critical to medication selection, dosing, and frequency (i.e., diabetes, kidney disease, liver disease, mental illness) or is in receipt of a "high-alert" medication with known precautions (e.g., warfarin, insulin, opiates), may provide benefits similar to those of automated alerts. Importantly, many of these strategies involve enhanced communication within and across practices, something that is hard to argue with and would not be improved by automated message systems.
In conclusion, while it is well and good to highlight variation in prescriber practice and response to messages regarding inappropriate prescribing, true system change will require improvements in infrastructure and communication to reduce the likelihood of medication errors and correct such errors when they do occur.